The purpose of this module is to provide comprehensive information pertaining to basic medical asepsis and isolation precautions for easily transmitted diseases.
At the completion of this module, you will be able to:
The term "hand hygiene" refers to both handwashing with an antimicrobial or plain soap and water as well as alcohol-based products such as gels, foams, and rinses. Alcohol-based products contain an emollient that does not require the use of water. According to the most up-to-date infection-control guidelines from the Centers for Disease Control and Prevention, in the absence of visible soiling of hands and when contamination from spore-forming organisms such as Clostridium difficile is unlikely, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbicidal activity, reduced drying of the skin, and convenience. Overall, hand hygiene remains the most important measure for preventing the transmission of micro-organisms.
Upon arrival to work, inspect the surface of your hands for breaks or cuts in the skin or cuticles. If lesions are found, apply dressing prior to providing care to patients.
Perform hand hygiene before caring for a patient and after contact with anything in the room. Perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Perform hand hygiene immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of micro-organisms to other patients or environments. It may be necessary to perform hand hygiene between tasks and procedures on the same patient to prevent cross-contamination of different body sites.
Avoid artificial nails, which harbor micro-organisms, and keep nails trimmed to one quarter of an inch when caring for patients. In addition, avoid wearing rings whenever possible. If the areas under fingernails are soiled, clean them with the fingernails of the other hand or with an orangewood stick. Wash hands with soap and water when hands are visibly soiled.
Wet the hands, keeping the hands lower than the elbows.
Apply 3 to 5 mL of soap to the hands, coating all surfaces.
Rub the hands vigorously together, working up a lather, for at least 15 seconds.
Rinse thoroughly, pointing the fingers down to allow water to run off the hands.
Dry the hands from the fingers to the wrist.
Turn off the water with a clean paper towel.
Apply 3 to 5 mL (per manufacturer) of antiseptic gel to the palm of one hand.
Rub the hands together, coating all surfaces, and rub vigorously until the gel disappears and the hands are dry.
Disposing properly of patient-care equipment contaminated with blood, body fluids, secretions, and excretions is essential for preventing the spread of micro-organisms to other patients and environments. Do not use reusable equipment for the care of other patients until it has been cleaned and reprocessed appropriately.
Most facilities have procedures in place for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces. Be sure these procedures are being followed.
Dispose of sharp instruments such as needles, syringes, and scalpels in a puncture-resistant container. To prevent injuries, never break, recap, bend, or manipulate sharp instruments before disposing of them.
Dispose of blood, body fluids, suctioned fluids, and excretions by flushing them into the sewage system or per agency protocol. When dumping potentially infectious fluid, be especially careful not to splash it on your uniform or on the surrounding environment. Dispose of the emptied container in the appropriate receptacle.
Consider all specimens potentially infectious, and collect them in a container that closes securely. Avoid contamination of the outside of the container. Most agencies require placing the specimen in a plastic bag labeled as "Biohazard" before transporting.
Handle linens soiled with blood, body fluids, secretions, and excretions carefully, and, to protect other healthcare workers, transport them in a leak-resistant bag.
Hold soiled linens away from the body to prevent contamination of clothes. Avoid shaking or tossing linens, as this can spread micro-organisms to other patients and environments. Also, to prevent transmitting infection, do not place soiled linens on the floor. If clean linens touch the floor or any unclean surface, immediately place them in the soiled linen container.
Personal protective equipment (PPE) such as gloves, gowns, masks, and eyewear may be necessary to avoid contact with blood, body fluids, secretions, and excretions and the transmission of infectious material found in these substances.
Wear clean, nonsterile gloves when touching blood, body fluids, secretions, excretions, and contaminated items, including respiratory secretions, and when providing oral care or handling soiled tissues. Also, use clean gloves just before touching mucous membranes and non-intact skin. Gloves should fit comfortably and not be reused. The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves.
Perform hand hygiene until the product disappears and the hands are dry.
Select the appropriate size glove.
Holding the glove at the opening, slip the fingers into the glove and pull tight.
With the gloved hand, hold the second glove at the opening and slip the ungloved fingers into the glove and pull tight.
Pull gloves to the wrists of both hands.
Remove the gloves by grasping the cuff of the other gloved hand.
Avoiding skin contact, roll the glove inside out and place it in the palm of the gloved hand.
Grasp the glove on the inside of the cuff and pull inside out.
Dispose of the gloves.
Perform hand hygiene.
Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of micro-organisms.
Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transferring micro-organisms to other patients or environments.
Wear sterile gloves when following the principles of surgical asepsis for keeping an area/object free of all micro-organisms. Thorough handwashing must be performed before donning sterile gloves and after discarding the gloves. Detailed guidelines for the use of sterile gloves are found in the module entitled, Surgical Asepsis.
Masks provide barriers to infectious materials and are often used with other personal protective equipment such as gowns and gloves. When worn properly, masks and eye protection provide protection for the mouth, nose, and eyes during procedures where there is a potential for droplets or splashing of blood or body fluids. In addition to these standard precautions, special precautions are mandated by the CDC for airborne, droplet, and contact involving highly transmissible diseases such as measles, varicella, tuberculosis, influenza, mumps, rubella, wound infections, scabies, and many other infectious diseases.
Procedure masks are flat/pleated and affix to the head with ear loops. They are used for any nonsterile procedure.
Surgical masks come in two basic types: One type is affixed to the head with two ties, conforms to the face with the aid of a flexible adjustment for the bridge of the nose, and may be flat/pleated or duck-billed in shape. The second type of mask is pre-molded, adheres to the head with a single elastic band, and has a flexible adjustment for the bridge of the nose.
All masks have some degree of fluid resistance, but those approved as surgical masks must meet specified standards for protection from penetration of blood and body fluids.
Some masks have ties and some have elastic to secure the mask to the face. One is flexible and one is molded.
Both have a flexible nose piece that is adjusted by pinching at the bridge of the nose.
Place and hold the mask over the nose, mouth, and chin while stretching the band over the ear or tying the ties behind the head and at the base of the neck.
Adjust the mask so it is snug with no gaps. The mask should not be touched or readjusted during use.
After properly removing and disposing of gloves, carefully remove the elastic from the ear or untie the mask from the back of the head, bottom tie first.
Dispose of the mask.
Perform hand hygiene.
Respirators are used for case-specific procedures where particulates and secretions create a high risk of infection for the healthcare worker. Agencies typically have special procedures for these devices and provide special training and clearance for use.
Current OSHA standards require that respirators used for airborne precautions for suspected and confirmed pulmonary tuberculosis (TB) minimally filter 95% of 0.3 µm-size particles. The N95 respirator and the HEPA respirator meet these requirements. All personnel who care for patients with suspected and confirmed pulmonary TB must wear an N95/HEPA respirator when entering the patient's room. An N95 respirator mask is intended to be used for protection against solids. The N95 is extremely durable and has a soft and comfortable inner surface, an adjustable nosepiece, and secure headstraps to provide proper fit. A person using an N95/HEPA respirator must be fit-tested before use. Check with agency policy about respirator use for infection control.
Face and eye protection provide a barrier to infectious substances and are typically used in conjunction with other personal protective equipment such as gloves, gowns, and masks. The type of face and eye protection chosen depends on the specific work conditions and potential for exposure. There are a variety of devices including goggles, shields, safety glasses, and even full-face respirators. Personal knowledge of potential exposure is essential for making an informed decision about the right face and eye protection. Eyeglasses prescribed for vision correction and contact lenses are not considered eye protection. For complete and proper protection, it's also important to evaluate the combination of protection recommended for the specific work situation. For example, some masks may not work with various goggles or shields. Likewise, a full-face respirator may provide adequate protection without additional personal protective equipment.
Grasping the ear or head pieces of the appropriate device, spread and slowly apply the device over the ears.
Adjust for comfort as needed.
Using ungloved hands, grasp the ear pieces and lift away from the face.
Discard disposable devices in the appropriate receptacle. If the device is designed to be reused, process it according to agency protocol.
Goggles are available with direct or indirect venting. Direct-vented goggles have the potential for allowing the penetration of splashes and are not as reliable as indirect-vented goggles. Goggles must fit snugly to provide adequate protection from splashes, sprays, and respiratory droplets.
Face shields are sometimes used as an alternative to goggles. Because the shield has a larger surface area, it provides protection to other facial areas. Face shields do not fit snugly against the face, making them vulnerable to splash and spray going under the shield. Shields are typically used with other forms of protection and should not be considered the best protection.
Safety glasses are excellent for providing impact protection. However, they do not protect adequately from splash, spray, and respiratory droplets. Thus, they are not typically used for infection-control purposes.
A clean, nonsterile gown is adequate for protecting skin and preventing soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Most patient interactions do not require the use of a gown. Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly as possible and wash hands to avoid transferring micro-organisms to other patients or environments.
Select the appropriate type and size of gown.
With the gown opening in the back, pull the arms through the sleeves one at a time and pull it over the shoulders. Secure at the neck and waist.
If the gown is disposable and designed to be removed quickly, the gloves may be removed with the gown and rolled together to prevent contamination.
If not using a breakaway gown, untie the waist tie before removing the gloves. Remove gloves and with ungloved hands, untie the gown at the neck and pull it away from the shoulders. Roll it into a bundle while avoiding contact with the outside of the gown.
Dispose of the gown.
Perform hand hygiene.
Latex sensitivity and latex allergies are of concern to healthcare workers and patients. This is partly due to the potential for high exposure to latex gloves and medical supplies that contain latex.
Healthcare workers and patients who have a sensitivity or allergy to kiwifruit, papayas, avocados, bananas, potatoes, or tomatoes should be screened carefully as they have a higher chance of having a sensitivity or allergy to latex.
The three most common reactions to latex products are:
Rubber latex products often cause irritant contact dermatitis. Areas of the skin, usually the hands, become dry, itchy, and irritated. This reaction is caused by skin irritation from using gloves and possibly by exposure to other workplace products and chemicals. The reaction can also result from repeated handwashing and drying, incomplete hand drying, use of cleaners and sanitizers, and exposure to powders added to the gloves. Irritant contact dermatitis is not a true allergy.
Allergic contact dermatitis results from exposure to chemicals added to latex during harvesting, processing, or manufacturing. These chemicals cause skin reactions similar to those caused by poison ivy. The rash usually begins 24 to 48 hours after contact and may progress to oozing skin blisters or spread away from the area of skin touched by the latex.
The most serious reaction to latex is a latex allergy. The protein in rubber can cause an allergic reaction in some people. It can be a more serious reaction to latex than irritant contact dermatitis or allergic contact dermatitis. Also, when healthcare workers change gloves, the protein/powder becomes airborne and could be inhaled into the respiratory tract. Reactions usually begin within minutes of exposure to latex, but they can occur hours later and can produce various symptoms. Mild reactions to latex involve skin redness, hives, and itching. More severe reactions may involve symptoms such as runny nose, sneezing, itchy eyes, scratchy throat, and asthma (difficult breathing, coughing spells, and wheezing), and anaphylactic shock.
Once a healthcare worker or patient has been identified with a latex sensitivity or allergy, precautions must be taken to prevent exposure. Replacing latex-containing gloves and supplies with non-latex items is essential.
When a patient has been identified with a latex sensitivity or allergy, it is important that the entire healthcare team be aware. A latex-free cart supplied with latex-free items should be used for all care to prevent exposing the patient to latex.
In 2013, the Centers for Disease Control recommended that respiratory hygiene/cough etiquette be incorporated into infection control as one component of standard precautions. These should be instituted in the health care setting at the first point of contact with a potentially infected person to prevent the transmission of all respiratory infections. The recommended practices have a strong evidence base.
Respiratory hygiene/cough etiquette applies to anyone entering a healthcare setting: patients, visitors, and staff with signs or symptoms of illness, whether diagnosed or undiagnosed, including cough, congestion, rhinorrhea, or increased production of respiratory secretions. The components of respiratory hygiene/cough etiquette include:
Be sure to educate patients and families about these new guidelines. Also, be sure to observe standard and droplet precautions and hand hygiene when examining and caring for patients with signs and symptoms of a respiratory infection. It is also a good idea to post signs in languages appropriate for the population served, with instructions to patients and accompanying family members or friends reminding them of these recommendations.
There are currently two tiers of CDC precautions to prevent transmission of infectious agents: standard precautions and transmission-based precautions.
Standard precautions are applied to the care of all patients in all healthcare settings, regardless of suspected or confirmed presence of an infectious agent. Standard precautions are used with blood, blood products, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes. This includes infection prevention practices that apply to all patients: hand hygiene; use of gloves, gown, mask, and face shield; respiratory hygiene/cough etiquette; and safe injection practices. The practice is determined by the extent of anticipated blood, body fluid, or pathogen exposure.
The second tier addresses isolation precautions, which are based on the mode of transmission of a disease. There are three categories of transmission-based precautions: contact precautions, droplet precautions, and airborne precautions. These are used when the route of transmission is not completely interrupted by standard precautions. Transmission-based precautions are for patients who have highly transmissible pathogens.
Direct contact refers to the care and handling of contaminated body fluids.
Indirect care refers to the transfer of an infectious organism through a contaminated intermediate object, such as contaminated instruments or hands of healthcare workers.
Contact precautions include the use of personal protective equipment: gloves and gowns. These patients should also be in a private room to prevent cross-contamination. Examples of infections contact precautions are instituted for include VRE, MRSA, C. difficile, wound infections, and herpes simplex.
Droplet precautions are used when a disease is transmitted by large droplets expelled into the air and travels 3 to 6 feet from the patient.
This type of precaution requires the use of a surgical mask when within 3 feet of the patient, proper hand hygiene, and some dedicated care equipment. The mask should be applied prior to entering the patient’s room. Examples of a patient who requires droplet precautions include those who have influenza or Mycoplasma pneumonia.
Airborne precautions are used with patients who have diseases that are transmitted by smaller droplets. These droplets remain airborne for longer periods of time. This form of isolation requires a negative airflow. This airflow filters air through a high-efficiency particulate air (HEPA) filter and then directs the air to the outside of the facility.
This type of precaution requires the use of an N95 respirator each time healthcare workers enter the patient’s room. This mask should be applied prior to entering the room. This type of mask must be fitted properly prior to use. An example of a diagnosis that requires airborne precautions is pulmonary tuberculosis.
With all of these types of transmission-based precautions, certain basic principles should be followed.
The protective environment is designed for patients who have undergone transplants and gene therapy. This environment reduces the risk of environmental fungal infections. These patients require a private room with positive airflow and HEPA filtration for incoming air. The patient should wear a mask if they are out of the room during times of construction in the area. They are also not allowed to have fresh flowers or potted plants in their rooms.
Alsubaie, S., bin Maither, A., Alalmaei, W., Al-Shammari, A. D., Tashkandi, M., Somily, A. M., Alaska, A., & BinSaeed, A. A. (2013). American Journal of Infection Control, 41, 131-135.
This observational study was carried out in five intensive care units in Saudi Arabia to determine the factors associated with hand hygiene noncompliance. The World Health Organization’s “Five Moments for Hand Hygiene” procedure was used as a basis for the observations. The noncompliance rate was 58%. Factors associated with noncompliance included job title, working in the a.m. shift, working in the pediatric intensive care unit, and performance of hand hygiene before patient contact. Hand hygiene compliance was highest among therapists and technicians due to few patient interactions, while physicians had the lowest compliance rate.
The study identified many important factors that may be targeted during hand hygiene initiatives, including hand hygiene education and training for medical staff, a focus on daytime shifts, pediatric units, and reminders for hand hygiene prior to initial patient contact. The location and ease of access to alcohol-based hand rub dispensers was also noted as a modifiable factor.
Larson, E. L., Cohen B., & Baxer, K. A. (2012). American Journal of Infection Control, 40(9), 806-809.
In this study, the hands of 30 volunteers were inoculated with H1N1 and randomized to treatment with foam, gel, or hand wipes applied to half of each volunteer's finger pads. The viral count of each volunteer's treated and untreated finger pads were averaged. Treatment with each of the products was associated with a significant reduction in viral titers.
The authors concluded that alcohol-based foam, gel, or wipes provided significant reductions in viral counts on hands.
Casanova, L. M., Rutala, W. A., Weber, D. J., & Sobsey, M. D. (2012). American Journal of Infection Control, 40(4), 369-374.
A total of 18 volunteers who had previous experience using PPE participated. This experimental study had a single-gloving phase and a double-gloving phase. Participants donned PPE (contact isolation gown, N95 respirator, eye protection, latex gloves). Then the surface of the gown, respirator, eye protection, and glove of the dominant hand were contaminated with bacteriophage. Participants then removed the PPE. Their hands, face, and scrubs were sampled for virus. Transfer of virus to hands and scrubs during PPE removal was significantly more frequent with single-gloving than with double-gloving.
The researchers suggest that double-gloving can reduce the risk of viral contamination of hands during PPE removal and recommend further research in larger controlled studies.
Documentation is an essential component of patient care. Not only does it provide information about the care you give and the status of your patient, but it also communicates information to other healthcare workers to help assure both quality and continuity. Additional uses of documentation include: use in legal proceedings, reimbursement, education, research, and quality assurance.
The format used for documentation varies from agency to agency, so be sure to familiarize yourself with your agency’s format and follow it. Use only approved abbreviations and make sure all documentation is clear, concise, and legible. Maintain privacy and confidentiality of patient information at all times.
All healthcare providers, including students, have a legal and ethical obligation to follow HIPAA regulations. In clinical settings, students should only gather the information from the patient’s medical record that they need to provide safe and efficient care. Any written material students prepare and share, submit, or distribute must exclude the patient’s name, room number, date of birth, medical record number, and any other identifiable demographic information.
Documentation for infection control should include the following and any additional information pertinent to a procedure:
QIDs: 65809, 65810, 65813, 65815, 65817, 65820
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